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Clinical Nutrition
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Article history:
Received 4 February 2009
Accepted 31 March 2009
When planning parenteral nutrition (PN), the proper choice, insertion, and nursing of the venous access
are of paramount importance. In hospitalized patients, PN can be delivered through short-term, nontunneled central venous catheters, through peripherally inserted central catheters (PICC), or for limited
period of time and with limitation in the osmolarity and composition of the solution through
peripheral venous access devices (short cannulas and midline catheters). Home PN usually requires PICCs
or if planned for an extended or unlimited time long-term venous access devices (tunneled catheters
and totally implantable ports).
The most appropriate site for central venous access will take into account many factors, including the
patients conditions and the relative risk of infective and non-infective complications associated with
each site. Ultrasound-guided venepuncture is strongly recommended for access to all central veins. For
parenteral nutrition, the ideal position of the catheter tip is between the lower third of the superior cava
vein and the upper third of the right atrium; this should preferably be checked during the procedure.
Catheter-related bloodstream infection is an important and still too common complication of parenteral
nutrition. The risk of infection can be reduced by adopting cost-effective, evidence-based interventions
such as proper education and specic training of the staff, an adequate hand washing policy, proper
choices of the type of device and the site of insertion, use of maximal barrier protection during insertion,
use of chlorhexidine as antiseptic prior to insertion and for disinfecting the exit site thereafter, appropriate policies for the dressing of the exit site, routine changes of administration sets, and removal of
central lines as soon as they are no longer necessary.
Most non-infective complications of central venous access devices can also be prevented by appropriate,
standardized protocols for line insertion and maintenance. These too depend on appropriate choice of
device, skilled implantation and correct positioning of the catheter, adequate stabilization of the device
(preferably avoiding stitches), and the use of infusion pumps, as well as adequate policies for ushing
and locking lines which are not in use.
2009 European Society for Clinical Nutrition and Metabolism. All rights reserved.
Keywords:
Guidelines
Evidence-based
Clinical practice
Parenteral nutrition
Central venous access
Venous access devices
Midline catheters
PICC
Central venous catheters
Totally implantable ports
Tunneled catheters
Peripheral parenteral nutrition
Home parenteral nutrition
Ultrasound guidance
Catheter-related bloodstream infection
Needle-free connectors
Chlorhexidine
Antibiotic lock therapy
Exchange over guide wire
Heparin lock
Sutureless securing devices
Catheter-related venous thrombosis
Pinch-off syndrome
Fibrin sleeve
0261-5614/$ see front matter 2009 European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2009.03.015
366
Recommendations
Grade
Central venous access (i.e., venous access which allows delivery of nutrients directly into the superior vena
cava or the right atrium) is needed in most patients who are candidates for parenteral nutrition (PN).
In some situations however PN may be safely delivered by peripheral access (short cannula or midline
catheter), as when using a solution with low osmolarity, with a substantial proportion of the non-protein
calories given as lipid.
It is recommended that peripheral PN (given through a short peripheral cannula or through a midline catheter)
should be used only for a limited period of time, and only when using nutrient solutions whose osmolarity
does not exceed 850 mOsm/L.
Home PN should not normally be given via short cannulas as these carry a high risk of dislocation and
complications.
Peripheral PN, whether through short cannulas or midline catheters, demands careful surveillance for
thrombophlebitis.
Number
1
Short-term: many non-tunneled central venous catheters (CVCs), as well as peripherally inserted central
catheters (PICCs), and peripheral catheters are suitable for in-patient PN.
Medium-term: PICCs, Hohn catheters, and tunneled catheters and ports are appropriate. Non-tunneled central
venous catheters are discouraged in HPN, because of high rates of infection, obstruction, dislocation, and
venous thrombosis.
Prolonged use and HPN (>3 months) usually require a long-term device. There is a choice between tunneled
catheters and totally implantable devices. In those requiring frequent (daily) access a tunneled device is
generally preferable.
The choice of vein is affected by several factors including venepuncture technique, the risk of related
mechanical complications, the feasibility of appropriate nursing of the catheter site, and the risk of thrombotic
and infective complications.
The use of the femoral vein for PN is relatively contraindicated, since this is associated with a high risk of
contamination at the exit site in the groin, and a high risk of venous thrombosis.
High approaches to the internal jugular vein (either anterior or posterior to the sternoclavicular muscle) are
not recommended, since the exit site is difcult to nurse, and there is thus a high risk of catheter
contamination and catheter-related infection.
Insertion of CVCs
High osmolarity PN requires central venous access and should be delivered through a catheter whose tip is in
the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium
(Grade A). The position of the tip should preferably be checked during the procedure, especially when an
infraclavicular approach to the subclavian vein has been used.
Postoperative X-ray is mandatory (a) when the position of the tip has not been checked during the procedure,
and/or (b) when the device has been placed using blind subclavian approach or other techniques which carry
the risk of pleuropulmonary damage.
C, B
There is limited evidence to suggest that the catheter material is important in the etiology of catheter-related
sepsis. Teon, silicone and polyurethane (PUR) have been associated with fewer infections than polyvinyl
chloride or polyethylene. Currently all available CVCs are made either of PUR (short-term and medium-term)
or silicone (medium-term and long-term); no specic recommendation for clinical practice is made.
Some interventions are not effective in reducing the risk of infection, and should not be adopted for this
purpose; these include:
in-line lters
routine replacement of central lines on a scheduled basis
antibiotic prophylaxis
the use of heparin
Diagnosis of catheter-related sepsis
Diagnosis of CRBSI is best achieved (a) by quantitative or semi-quantitative culture of the catheter (when the
CVC is removed or exchanged over a guide wire), or (b) by paired quantitative blood cultures or paired
qualitative blood cultures from a peripheral vein and from the catheter, with continuously monitoring of the
differential time to positivity (if the catheter is left in place).
367
Table (continued)
Summary of statements: Central Venous Catheters
Subject
Recommendations
Grade
Number
A short-term central line should be removed in the case of (a) evident signs of local infection at the exit site, (b)
clinical signs of sepsis, (c) positive culture of the catheter exchanged over guide wire, or (d) positive paired
blood cultures (from peripheral blood and blood drawn from the catheter). Appropriate antibiotic therapy
should be continued after catheter removal.
Removal of the long-term venous access is required in case of (a) tunnel infection or port abscess, (b) clinical
signs of septic shock, (c) paired blood cultures positive for fungi or highly virulent bacteria, and/or (d)
complicated infection (e.g., evidence of endocarditis, septic thrombosis, or other metastatic infections). In
other cases, an attempt to save the device may be tried, using the antibiotic lock technique.
Most central venous access devices for PN can be safely ushed and locked with saline solution when not in
use.
Heparinized solutions may be used as a lock (after ushing with saline), when recommended by the
manufacturer, in the case of implanted ports or opened-ended catheter lumens which are scheduled to remain
closed for more than 8 h.
10
Intraluminal obstruction of the central venous access can be prevented by appropriate nursing protocols in
maintenance of the line, including the use of nutritional pumps.
11
Prevention of catheter-related
central venous thrombosis
Thrombosis is avoided by the use of insertion techniques designed to limit damage to the vein, including
Ultrasound guidance at insertion
choice of a catheter with the smallest caliber compatible with the infusion therapy needed
position of the tip of the catheter at or near to the atrio-caval junction
12
Prophylaxis with a daily subcutaneous dose of low molecular weight heparin is effective only in patients at
high risk for thrombosis.
368
Prolonged use and HPN (>3 months) usually require a longterm device. There is a choice between tunneled catheters and
totally implantable device. In those requiring frequent (daily)
access a tunneled device is generally preferable (Grade B).
369
370
in-line lters
routine replacement of central lines on a scheduled basis
antibiotic prophylaxis
the use of heparin
371
gloves for the operator, and a large sterile drape for the insertion of
central venous access devices (Grade C). Full-barrier precautions
during CVC insertion are recommended by most other guidelines,
and this practice has been adopted by most bundles of evidencebased interventions aiming to reduce CRBSI, in multicenter
prospective trials.
Proper education and specic training of the staff is universally
recommended as one of the most important and evidence-based
strategy for reducing the risk of catheter-related infections (Grade
A). Specialized nursing teams should care for venous access devices
in patients receiving PN. There is good evidence demonstrating that
the risk of infection declines following the standardization of
aseptic care and increases when the maintenance of intravascular
catheters is undertaken by inexperienced healthcare workers. Also,
it has been proven that relatively simple education programs
focused on training healthcare workers to adhere to local evidencebased protocols may decrease the risk to patients of CRBSI.41,42 In
a very important multicenter prospective study carried out in 108
intensive care units, Provonost and coworkers43 have shown that
the adoption of a bundle of a small number of evidence-based
interventions (hand washing; full-barrier precautions during the
insertion of central venous catheters; skin antisepsis with chlorhexidine; avoiding the femoral site if possible; removing unnecessary catheters as soon as possible) was highly effective in
producing a clinically relevant (up to 66%) and persistent reduction
in the incidence of CRBSI.
The implementation of an adequate policy of hand washing
amongst healthcare workers who have contact with patients on PN
is considered one of the most evidence-based and cost-effective
maneuvers for reducing the risk of catheter-related infection
(Grade A). Good standards of hand hygiene and antiseptic technique can clearly reduce the risk of CR-infection.8,44 In particular:
before accessing or dressing a central venous access device, hands
must be decontaminated either by washing with an antimicrobial
liquid soap and water, or by using an alcohol hand rub. When
washing hands with soap and water, wet hands rst with water,
apply the amount of product recommended by the manufacturer to
hands, and rub hands vigorously for at least 15 s, covering all
surfaces of the hands and ngers; rinse hands with water and dry
thoroughly with a disposable towel. When decontaminating hands
with an alcohol-based hand rub, apply product to palm of one hand
and rub hands together, covering all surfaces of hands and ngers,
until hands are dry8; follow manufacturers recommendations
regarding the volume of product to use. Hands that are visibly
soiled or contaminated with dirt or organic material must be
washed with liquid soap and water before using an alcohol hand
rub. Evidence from RCTs has shown that when accessing a central
venous line (for insertion site dressing, line manipulation or
intravenous drug administration) there are two possible options:
(1) hand antisepsis clean gloves, and aseptic non-touch technique; (2) hand antisepsis sterile gloves (Grade C).
The most appropriate skin antiseptic for prevention of catheterrelated bloodstream infection is chlorhexidine as 2% solution in 70%
isopropyl alcohol, and it should be preferred for both skin preparation before catheter insertion and cleaning of the catheter exit
site (Grade A). Recent clinical randomized study45 indicates that
chlorhexidine, particularly as 2% chlorhexidine gluconate in 70%
isopropyl alcohol, is the most appropriate antiseptic for preparation
of the insertion site as well as for cleansing the entry site once the
catheter is in place (Grade A).
An aqueous solution of chlorhexidine gluconate should be
used if the manufacturers recommendations prohibit the use of
alcohol with their product (such as in the case of some PUR
catheters). Alcoholic povidoneiodine solution should be used in
patients with a history of chlorhexidine sensitivity (Grade A).
372
and after use with a single patient use application of a 70% alcoholic
solution or a 2% chlorhexidine gluconate solution unless contraindicated by the manufacturers recommendations (Grade C).
The intravenous catheter administration set should be changed
every 24 h (when using lipid PN) or every 72 h (if lipids are not
infused) (Grade C). In-line lters are not recommended for the
prevention of CR-BSI (Grade C). No evidence has been found to
support the use of in-line lters for preventing infusate-related CRBSI. However, there may be a role for the use of in-line ltration of
lipid-based PN solutions in selected cases, under a pharmacists
recommendation, for ltering micro-aggregates possibly occurring
in the emulsion.
Non-tunneled CVCs should not be removed and replaced
routinely (Grade A), and they should not be changed routinely over
a guide wire (Grade A). Such strategies are not associated with
a reduction of CRBSI and may actually increase the rate of complications. Routine removal and replacement of the CVC without
a specic clinical indication does not reduce the rate of catheter
colonization or the rate of CR-BSI, but increases the incidence of
insertion-related complications. CVCs should be removed only if
complications occur or they are no longer necessary (Grade A).
Guide wire assisted catheter exchange has a role in replacing
a malfunctioning catheter, but is contraindicated in the presence of
infection at the catheter site or proven CRBSI. Guide wire exchange
may have a role in diagnosis of CRBSI. If catheter-related infection is
suspected, but there is no evidence of infection at the catheter site,
the existing catheter may be removed and a new catheter inserted
over a guide wire; if tests reveal catheter-related infection, the
newly inserted catheter should be removed and, if still required,
a new catheter inserted at a different site. If there is evidence of
infection at the exit site or evidence of CRBSI, the catheter should be
removed and not exchanged over guide wire. All uid administration tubing and connectors must also be replaced when the central
venous access device is replaced (Grade C).
Prophylactic administration of systemic or local antibiotics
before or during the use of a CVC is not recommended, since it does
not reduce the incidence of CR-BSI (Grade A).5052
Prophylaxis with an antibiotic lock has been shown to be
effective only in neutropenic patients with long-term venous
access. There is no evidence that routinely using this procedure in
all patients with CVC will reduce the risk of catheter-related
bloodstream infections, and this is not recommended (Grade C).
Low-dose systemic anticoagulation, periodic ushing with
heparin, or heparin lock, do not reduce the risk of catheter
contamination, and are not recommended for prevention of CRBSI
(Grade C). There is no denite evidence that heparin reduces the
incidence of CR-BSI, but this may reect the heterogeneity of
heparin concentration used and its modality of administration.
Many substances (taurolidine, citrate, EDTA, ethanol, etc.) have
been proposed for ushing and locking the catheter for the purpose
or reducing the formation of biolm inside the catheter and/or
reducing the colonization of the device and/or reducing the risk of
CRBSI, but there is not enough evidence to give recommendations
in this regard.
d) Management of catheter-related bloodstream infections
7. Which is the best method for diagnosis of CRBSI?
Diagnosis of CRBSI is best achieved (a) by quantitative or semiquantitative culture of the catheter (when the CVC is removed or
exchanged over a guide wire), or (b) by paired quantitative blood
cultures or paired qualitative blood cultures from a peripheral
vein and from the catheter, with continuously monitoring of the
differential time to positivity (if the catheter is left in place)
(Grade A).
373
374
375
Venous thrombosis (local or more seldom central) is occasionally associated with PICCs; it is apparently a multifactorial
phenomenon, inuenced by the caliber of the catheter,63 the
technique of placement (US-guided versus blind), the vein cannulated (cephalic versus brachial versus basilic), the position of the
tip, the stabilization technique (Statlock versus tape versus
stitches), the type of treatment,64 and factors related to the patient
and the underlying disease. Preventative measures are discussed
above: PICCs should not be inserted in paretic or immobilized arms,
since the risk of thrombosis is particularly high in these conditions
(Grade C).
The brin sleeve (or brin sheath) is a sleeve derived from
broblastic tissue which slowly covers the intraluminal and
extraluminal surfaces of long-term catheters; it may be unapparent, but can be associated with a persistent problem with
Table 1
Guidelines on venous access and venous access devices produced by other national
and international bodies. The topics have been widely and repeatedly addressed
with considerable conformity in the major conclusions. They are included here to
demonstrate this, and also (through their own citation of primary publications) to
help limit an otherwise very lengthy list of primary sources.
ACS 2008 American College of Surgeons. Statement on recommendations for
uniform use of real-time ultrasound guidance for placement of central venous
catheters. 2008. http://www.facs.org/fellows_info/statements/st-60.html
AVA 2008 Association for Vascular Access. Position Statement on the Use of RealTime Imaging Modalities for Placement of Central Venous Access Devices. 2008.
www.avainfo.org
ASPEN 2002 ASPEN Board of Directors and the Clinical Guidelines Task Force:
Guidelines for the use of parenteral and enteral nutrition in adult and pediatric
patients. JPEN 2002, vol. 26 (n. 1, suppl.): pp. 36SA-37SA
ASPEN 2004 Task Force for the Revision of Safe Practices for Parenteral Nutrition:
Safe Practices for Parenteral Nutrition. JPEN 2004, Vol. 8, n. 6: pp. S40S70
AUSPEN 2008 Gillanders L, Angstmann K, Ball P et al.: AuSPEN clinical practice
guideline for home parenteral nutrition patients in Australia and New Zealand.
Nutrition 2008, 24: 9981012.
BCSH 2006 British Committee for Standards in Haematology: Guidelines on the
insertion and management of central venous access devices in adults. Published
in 2006 and diffused by the British Society for Haematology, 100 White Lion
Street, London. Available on www.evanetwork.info
CDC 2002 Centers for Disease Control and Prevention: Guidelines for the
Prevention of Intravascular Catheter-Related Infections. MMWR 2002; 51(No.
RR-10): pp. 132. Available on www.evanetwork.info
EPIC 2007 Pratt RJ, Pellowe CM, Wilson JA et al.: EPIC2: National Evidence-Based
Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in
England. Journal of Hospital Infection (2007) 65S, S1S64. Available on www.
evanetwork.info
GAVeCeLT 2007 Campisi C, Bif R, Pittiruti M and the GAVeCeLT Committee for the
Consensus: Catheter-Related Central Venous Thrombosis The Development of
a Nationwide Consensus Paper in Italy. JAVA 2007, Vol 12 (No 1): pp. 3846.
Available on www.evanetwork.info
IDSA 2001 Mermel LA, Farr BM, Sherertz RJ at al.: Guidelines for the Management
of Intravascular Catheter-Related Infections. Clinical Infectious Diseases 2001;
32:124972. Available on www.evanetwork.info
INS 2006 Infusion Nurses Society: Infusion Nursing Standards of Practice. Journal
of Infusion Nursing, vol. 29 (suppl. 1): pp. S1S92.
NICE 2002 National Institute for Clinical Excellence: Guidance on the use of
ultrasound locating devices for placing central venous catheters. September 2002.
Published and diffused by National Institute for Clinical Excellence, 11 Strand,
London. Available on www.nice.org.uk and on www.evanetwork.info
RCN 2005 Royal College of Nursing I.V. Therapy Forum: Standards for infusion
therapy. November 2005. Published by the Royal College of Nursing, 20 Cavendish
Square, London. Available on www.rcn.org.uk and on www.evanetwork.info
RNAO 2004 Registered Nurses Association of Ontario, Nursing Best Practice
Guidelines Project: Assessment and Device Selection for Vascular Access. May
2004. Published and diffused by the Registered Nurses Association of Ontario, 111
Richmond Street West, Suite 1100, Toronto, Ontario (Canada). Available on www.
rnao.org/bestpractices and on www.evanetwork.info
SINPE 2002 Linee Guida SINPE per la Nutrizione Articiale Ospedaliera. RINPE
2002, anno 20 (suppl. 5): pp. S21S22, pp. S29S33
SHEA/IDSA 2008 SHEA/IDSA practice recommendations Strategies to Prevent
Central LineAssociated Bloodstream Infections in Acute Care Hospitals. Infect
Control Hosp Epidemiol 2008; 29: S22S30.
376
withdrawal from, or complete occlusion of the catheter. Its pathogenesis is unknown and there are not enough data to formulate
evidence-based recommendations with regards to its prevention
and treatment.
Conict of interest
Conict of interest on le at ESPEN (espenjournals@espen.org).
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